Exit and NCLEX Examination Study Guide

DIAGNOSIS PLANNING IMPLEMENTATION Nursing process- REMEMBER ASSESS FIRST BEFORE IMPLEMENTATION – ASK YOURSELF IS THERE ENOUGH INFORMATION GIVEN TO TAKE ACTION. YOU CANNOT IMPLEMENT UNLESS YOU HAVE ENOUGH INFORMATION EXAMPLE The night after an exploratory laparotomy, a patient who has a nasogastric tube attached to low suction reports nausea. A nurse should take which of the following action first? a. Administer the prescribed antiemetic to patient b. Determine the patency of the patient’s nasogastric tube c. Instruct the patient to take deep breathes d. Assess the patient’s pain level RATIONALE THE PATIENT IS COMPLANING OF NAUSEA, THERE IS NO EVIDENCE OF ISSUES WITH AIRWAY OR BREATHING. THE QUESTION IS ASKING, WHAT IS THE FIRST THING YOU WOULD DO FOR THIS PATIENT WHO IS REPORTING NAUSEA. The A, B, C’s are eliminated, use the nursing process, Answers A and C are implementation. Do you have enough information to ACT. Do you know why you are acting? Assess first! Answer D is tempting because you see the words assess, but ask yourself: IS PAIN THE ISSUE HERE, NAUSEA IS THE ISSUE HERE. NOT PAIN. IT IS IMPORTANT TO FIGURE OUT WHATS CAUSING THE NAUSEA ANSWER B – IS POSSIBLE WHY? PRIOR TO AN EXPLORATORY LAPAROTOMY , A PATIENT HAS A NASOGASTRIC TUBE INSERTED TO DECOMPRESS THE STOMACH . NAUSEA CAN BE CAUSED BY DISTENTION OR INADEQUATE DRAINAGE. 6 1. ABC Come first WHAT IF YOU DO NOT HAVE ABC’S Airway isn’t always right! CASE IN POINT “My toe hurts!” says the ED client. “OK, let me check your airway,” says new nurse. “I don’t think so!” says the nursing instructor 2. Next is your patient with change in level of consciousness- safety issue ****Check LOC before check pedal pulses/ Compare current BP with previous BPs**** Table 1: Classification of Altered Levels of Consciousness A. Confusional States- Confusion is a state in which the patient cannot take into account all elements of his/her immediate environment, implying an element of sensorial clouding. Apathy and drowsiness are often prominent and accompanied by disorientation primarily for time, less often for place, and rarely for self. Motor abnormalities such as tremor, asterixis and difficulty in motor relaxation may occur.Mild confusional states are common, especially in elderly patients exposed to hospital care or the trauma of major surgery B. Delirium- Delirium is a common and difficult problem especially in ill elderly patients. It is characterized by a fluctuating disturbance in consciousness and change in cognition that usually develops over a short period of time. Ten to fifteen percent of elderly patients may be delirious on arrival to the hospital and up to 55% may become delirious following admission. Delirium is often accompanied by increased morbidity and subsequent functional decline. C. Obtundation - Obtundation is primarily characterized by reduced alertness and hypersomnia. Hypersomnia is technically defined as a state of sleep in excess of 25% of the expected normal. When awakened from an obtunded state, the patient remains drowsy and confused and wakefulness can only be maintained by continuous verbal and painful stimuli. It is common to see the patient spontaneously changing postures in bed, drawing up the bed-sheets, and trying to pull out intravenous needles and indwelling catheters D. Stupor*- Stupor is unresponsiveness from which the patient can only be aroused by vigorous repeated painful stimuli. There is no response to verbal stimuli, and the response to pain becomes progressively less as the level of stupor deepens. The patient is unable to localize the site of the painful stimuli and, at best, the response is slow and stereotyped. Mental and physical activity is reduced to a minimum. Although unresponsive to many stimuli, the patient can open his/her eyes, look at the examiner and does not appear to be unconscious. Deep tendon reflexes are usually intact, but there may be evidence of muscle twitching, restless or stereotyped motor activity and grasping and sucking reflexes. 7 Catatonic stupor is seen most commonly in young people affected by catatonic schizophrenia. The patient lies with eyes open or tightly closed, resisting passive eye opening. There is an absence of spontaneous movements. E. Coma* - The patient who appears to be asleep and is at the same time incapable of responding adequately to either external stimuli or internal needs is in a state of coma. Coma may vary in degree from light to medium to deep. At its deepest stages, no reaction of any type is obtainable from the patient. Corneal, pupillary, pharyngeal, tendon and plantar reflexes are all absent. Opisthotonos and extensor rigidity of the limbs are suggestive of a decerebrate state. Respirations are often slow and Cheynes-Stokes in character. In lighter stages of coma (sometimes referred to as semicoma), most of the above mentioned reflexes can be elicited. Very painful stimuli may cause the patient to stir or moan. The Glasgow Coma Scale (GCS) is the most widely accepted method for the evaluation and classification of coma, especially for head-injured patients. As shown in Table 2, the GCS grades three neurologic parameters. Patients who open their eyes spontaneously, obey commands and are oriented score a total of 15 points, the best possible score, whereas flaccid patients, who neither open their eyes or verbalize, score the minimum of 3 points. A GCS score of 8 or less is the generally accepted definition of coma. Those with a GCS of 8 or less are classified as severe, while those with a GCS score of 9 to 12 are categorized as moderate and those with a GCS score of 13 to 15 are mild. Coma grades 3 to 5 indicate potentially fatal damage, especially if accompanied by fixed pupils or absent oculovestibular responses. Conversely, scores of 9 and above correlate with good recovery. *Both stupor and coma are often further classified as mild, moderate or deep. 3. Infection or type of Sepsis becomes a priority (a patient with sepsis take higher priority than someone in pain after a surgical procedure 4. LABS that directly correlate to your heart and lungs (abg show respiratory acidosis leading criteria for acute respiratory distress syndrome, those labs directly relate to our ABC. This patient would go higher than someone with an infection. THAT PATIENT WOULD BE A PRIORITY. 5. Does the patient have a high troponin